What is the maximum recommended dose of lisinopril (angiotensin-converting enzyme inhibitor) for patients with hypertension or heart failure?

Maximum Dose of Lisinopril for Hypertension and Heart Failure

The maximum recommended dose of lisinopril is 40 mg daily for both hypertension and heart failure, though doses up to 80 mg have been used in hypertension without additional benefit. 1

Dosing Guidelines by Indication

For Hypertension:

• Initial dose: 10 mg once daily
• Usual maintenance range: 20-40 mg once daily
• Maximum dose: 40 mg daily (doses up to 80 mg have been used but don't provide greater effect) 1
• When used with diuretics: Start with 5 mg once daily

For Heart Failure:

• Initial dose: 5 mg once daily (when used with diuretics and usually digitalis)
• For patients with hyponatremia (serum sodium <130 mEq/L): Start with 2.5 mg once daily
• Maximum dose: 40 mg once daily 1
• Titration: Increase as tolerated to maximum dose

Evidence from Clinical Trials

The ATLAS trial specifically compared high-dose lisinopril (32.5-35 mg daily) versus low-dose lisinopril (2.5-5 mg daily) in heart failure patients and found that high-dose therapy provided significant clinical benefits: 2, 3

• 8% lower risk of all-cause mortality
• 12% lower risk of death or hospitalization for any reason
• 24% fewer hospitalizations for heart failure

Dosing in Special Populations

Renal Impairment:

• Creatinine clearance >30 mL/min: No dose adjustment required
• Creatinine clearance 10-30 mL/min: Start with half the usual dose (hypertension: 5 mg; heart failure: 2.5 mg)
• Creatinine clearance <10 mL/min or on hemodialysis: Start with 2.5 mg once daily 1
• Maximum dose remains 40 mg daily regardless of renal function, though careful titration is needed

Pediatric Patients (≥6 years with hypertension):

• Starting dose: 0.07 mg/kg once daily (up to 5 mg total)
• Maximum dose: 0.61 mg/kg once daily (up to 40 mg) 1

Practical Dosing Approach

1. Start low: Begin with appropriate initial dose based on indication and renal function
2. Titrate gradually: Increase dose at 2-week intervals 2
3. Monitor closely: Check blood pressure, renal function, and electrolytes 1-2 weeks after each dose increment 2
4. Target optimal dose: Aim for the target dose shown effective in clinical trials (20-40 mg for hypertension, up to 40 mg for heart failure) 2, 1

Common Pitfalls to Avoid

• Underdosing: Many clinicians use doses that are too low for optimal benefit. The ATLAS trial showed significant advantages of higher doses (32.5-35 mg) over lower doses (2.5-5 mg) in heart failure patients 2, 3
• Inadequate monitoring: Monitor renal function and electrolytes after initiation and with each dose increase
• Failure to adjust for renal impairment: Patients with reduced renal function need lower initial doses but can still be titrated to effective doses with careful monitoring
• Premature discontinuation: Temporary side effects like mild hypotension or small increases in creatinine often don't require stopping therapy 2

Remember that while the maximum dose is 40 mg daily, the goal is to reach the highest tolerated dose within this range that effectively controls blood pressure or improves heart failure symptoms.